Provider Demographics
NPI:1962644401
Name:COLONIAL HOUSE OF CRYSTAL CITY, LLC
Entity Type:Organization
Organization Name:COLONIAL HOUSE OF CRYSTAL CITY, LLC
Other - Org Name:COLONIAL HOUSE OF CRYSTAL CITY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ALYSHA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SAUER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-933-4911
Mailing Address - Street 1:115 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-1733
Mailing Address - Country:US
Mailing Address - Phone:636-933-4911
Mailing Address - Fax:636-933-9550
Practice Address - Street 1:26 MISSISSIPPI AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL CITY
Practice Address - State:MO
Practice Address - Zip Code:63019-1817
Practice Address - Country:US
Practice Address - Phone:636-937-1000
Practice Address - Fax:636-937-1003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities